Transcript 14347: Proliferating Trichilemmal Cyst Presenting as Limbal Mass

Proliferating Trichilemmal Cyst
Presenting as Limbal Mass
Dr Pawan Prasher
Sri Guru Ram Das Institute of Medical
Sciences and Research, Amritsar, India
Financial Disclosure: No financial interest
Introduction
– Management of limbal mass can be challenging in terms
of establishing clinical diagnosis, histopathology and
treatment
– Differential diagnoses for limbal mass include
pinguecula, pterygium, papilloma, nodular episcleritis,
phlycten, nevus, granuloma, dermoid, lymphoma, CIN,
malignant melanoma, squamous cell carcinoma, ectopic
lacrimal gland tissue, hemangioma, nodular fasciitis,
amyloidosis and in association with dermatological
disorders like xeroderma pigmentosum
– Histopathology plays a key role in the management of
suspicous lesions
– Presented herein, is a case of proliferating trichilemmal
cyst that presented as a limbal mass
Case Report
• A 25-year-old female
presented with
gradually increasing
mass in the left eye for
over one month.
• Associated with redness,
mild irritation and
watering.
• No history of trauma,
surgery or any similar
episode in the past.
• No history of any
associated ocular or
systemic illness
Ocular examination
• Visual acuity was 20/20 both eyes
• Slit lamp examination showed
elevated nodular mass measuring
5 x 4 x 3mm at nasal limbus of
left eye.
• The mass had gelatinous, pearly
white appearance in the center
with dilated vessels in the
peripheral part.
• Associated epithelial irregularity
of the adjacent cornea.
• The mass appeared to be mobile
over the underlying tissues and
was non-tender.
• The rest of ocular and systemic
examination was unremarkable.
• The patient underwent excisional biopsy of limbal mass
• Under local peribulbar anaesthesia, the mass was
excised with 2mm surrounding healthy conjunctival
tissue
• The mass was found not to be adherent to the
underlying tissues
• The excision was followed by application of 0.04%
mitomycin-C application on the scleral bed for 2
minutes
• Excised mass was sent for histopathology
• Post-operatively patient was put on topical
moxifloxacin eye drops four times daily, prednisolone
eye drops four times daily and ciprofloxacin eye
ointment at bedtime
Histopathology
• Presence of islands of
squamous cells with
keratin filled cysts in the
substantia propria.
Histopathology
• Cysts lined by stratified
squamous epithelium
• The squamous cells showed
abrupt keratinization,
without any granular layer,
consistent with trichilemmal
keratinization
• There was no evidence of
atypia.
• There was formation of
early pyogenic
granuloma at 2 weeks
post-op which resolved
on increasing the
frequency of topical
prednisolone eye drops
to every 2 hours.
• At one year post-op,
patient showed well
healed conjunctiva with
no evidence of
recurrence in the area
of excision.
Discussion
• Trichilemmal cyst arises from outer root sheath
epithelium of hair follicle
• Also known as wen, pilar cyst or isthmus-catagen cyst
• Most often found on the scalp, but has also been
reported to occur in buccal mucosa
• Formation of proliferating trichilemmal cyst in the
current case could be as a result of implantation of hair
follicle cells from eyelashes while rubbing or migration
from caruncle
• Management of trichilemmal cysts includes wide local
excision with continued long-term surveillance
Discussion
• Being keratinous cysts, these cysts are similar to
epidermal cysts
• Key differentiating feature: trichilemmal
keratinization
• In this pattern, cells undergo an abrupt transition
from the stratum spinosum to the keratinized
layer without the formation of the granular layer
• Rarely, trichilemmal cysts can become malignant
Conclusions
• Proliferating trichilemmal cyst can present as a
gradually progressing limbal mass
• It is a benign condition that needs to be distinguished
from malignant squamous cell carcinoma which has
similar presentation but different prognosis
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